Safe Injection Self-Efficacy is associated with HCV and HIV seropositivity among people who inject drugs in the San Diego-Tijuana border region.

Background: Safe injection self-efficacy (SISE) is negatively associated with injection risk behaviors among people who inject drugs (PWID) but has not been examined in differing risk environments. We compared responses to a validated SISE scale between PWID in San Diego, California and Tijuana, Mexico, and examine correlates of SISE among PWID in Tijuana. Methods: PWID were recruited via street outreach for a longitudinal cohort study from October 2020 - September 2021. We compared SISE scale items by city. Due to low variability in SISE scores among San Diego residents, we restricted analysis of factors associated with SISE to Tijuana residents and identified correlates of SISE scores (low, medium, high) using ordinal logistic regression. Results: Of 474 participants, most were male (74%), Latinx (78%) and Tijuana residents (73%). Mean age was 44. Mean SISE scores among San Diego residents were high (3.46 of 4 maximum) relative to Tijuana residents (mean: 1.93). Among Tijuana residents, White race and having previously resided in San Diego were associated with higher SISE scores. HCV and HIV seropositivity, homelessness, fentanyl use, polysubstance co-injection, and greater injection frequency were associated with lower SISE scores. Conclusions: We found profound inequalities between Tijuana and San Diego SISE, likely attributable to differential risk environments. Associations with fentanyl and polysubstance co-injection, injection frequency, and both HIV and HCV seropositivity suggest that SISE contribute to blood-borne infection transmission risks in Tijuana. SISE reflects an actionable intervention target to reduce injection risk behaviors, but structural interventions are required to intervene upon the risk environment.

Police-mental health co-response versus police-as-usual response to behavioral health emergencies: A pragmatic randomized effectiveness trial.

BACKGROUND: People with mental illness are overrepresented in United States (US) criminal legal systems. In response, alternatives to traditional police response to behavioral health emergencies have become more common, despite limited evidence for their effectiveness. We conducted the first randomized controlled trial of a police-mental health co-response team to determine program effectiveness relative to a police-as-usual response on key outcomes identified by community stakeholders. METHODS: Between January 2020 and March 2021, we randomized behavioral health emergency calls for service in one of six police districts in Indianapolis, Indiana to receive a co-response or police-as-usual response during operational hours between 10 a.m. and 5 p.m. Mondays - Fridays. Eligible calls for service were determined via pre-specified phrases indicating a behavioral health incident over the police dispatch radio. Researchers then communicated random assignment with the co-response team to indicate whether they should respond or withhold. Logistic and negative binomial regression were used to assess group differences in emergency medical services (EMS) events within 12 months of the randomized incident along with jail booking, outpatient encounters, and emergency department visits. FINDINGS: We randomized 686 calls for service with co-response completed in 264 cases and police-as-usual response in 267 cases. The overall rate of attrition was similar across conditions and the final sample included 211 co-responses and 224 police-as-usual responses. We found no significant differences in any EMS event (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 0.85-1.88, p = .246) or event counts (incidence rate ratio [IRR]: 0.85; 95% CI: 0.52-1.37, p = .504). We also found no differences in secondary outcomes (jail booking, outpatient encounters, and emergency department visits). DISCUSSION: A police-mental health co-response team model was not more effective than traditional police response on key outcomes. Co-response team models, such as the one reported here, may unintentionally foster emergency services utilization among persons with behavioral health needs. Without a functioning national mental health system, communities in the US will continue to struggle to identify solutions to meet the needs of community members with complex behavioral health issues.

Drug checking in the fentanyl era: Utilization and interest among people who inject drugs in San Diego, California.

BACKGROUND: In North America, overdose rates have steeply risen over the past five years, largely due to the ubiquity of illicitly manufactured fentanyls in the drug supply. Drug checking services (DCS) represent a promising harm reduction strategy and characterizing experiences of use and interest among people who inject drugs (PWID) is a priority. METHODS: Between February-October 2022, PWID participating in a cohort study in San Diego, CA and Tijuana, Mexico completed structured surveys including questions about DCS, socio-demographics and substance use behaviors. We used Poisson regression to assess factors associated with lifetime DCS use and characterized experiences with DCS and interest in free access to DCS. RESULTS: Of 426 PWID, 72% were male, 59% Latinx, 79% were experiencing homelessness and 56% ever experienced a nonfatal overdose. One third had heard of DCS, of whom 57% had ever used them. Among the latter, most (98%) reported using fentanyl test strips (FTS) the last time they used DCS; 66% did so less than once per month. In the last six months, respondents used FTS to check methamphetamine (48%), heroin (30%) or fentanyl (29%). Relative to White/non-Latinx PWID, those who were non-White/Latinx were significantly less likely to have used DCS [adjusted risk ratio (aRR): 0.22; 95% CI: 0.10, 0.47), as were PWID experiencing homelessness (aRR:0.45; 95% CI: 0.28, 0.72). However, a significant interaction indicated that non-White/Latinx syringe service program (SSP) clients were more likely to have used DCS than non-SSP clients (aRR: 2.79; CI: 1.09, 7.2). Among all PWID, 44% expressed interest in free access to FTS, while 84% (of 196 PWID) expressed interest in advanced spectrometry DCS to identify and quantify multiple substances. CONCLUSIONS: Our findings highlight low rates of DCS awareness and utilization, inequities by race/ethnicity and housing situation, high interest in advanced spectrometry DCS versus FTS, and the potential role of SSPs in improving access to DCS, especially among racial/ethnic minorities.

Pilot Lightweight Denoising Algorithm for Multiple Sclerosis on Spine MRI.

Multiple sclerosis (MS) is a severely debilitating disease which requires accurate and timely diagnosis. MRI is the primary diagnostic vehicle; however, it is susceptible to noise and artifact which can limit diagnostic accuracy. A myriad of denoising algorithms have been developed over the years for medical imaging yet the models continue to become more complex. We developed a lightweight algorithm which utilizes the image's inherent noise via dictionary learning to improve image quality without high computational complexity or pretraining through a process known as orthogonal matching pursuit (OMP). Our algorithm is compared to existing traditional denoising algorithms to evaluate performance on real noise that would commonly be encountered in a clinical setting. Fifty patients with a history of MS who received 1.5 T MRI of the spine between the years of 2018 and 2022 were retrospectively identified in accordance with local IRB policies. Native resolution 5 mm sagittal images were selected from T2 weighted sequences for evaluation using various denoising techniques including our proposed OMP denoising algorithm. Peak signal to noise ratio (PSNR) and structural similarity index (SSIM) were measured. While wavelet denoising demonstrated an expected higher PSNR than other models, its SSIM was variable and consistently underperformed its comparators (0.94 ± 0.10). Our pilot OMP denoising algorithm provided superior performance with greater consistency in terms of SSIM (0.99 ± 0.01) with similar PSNR to non-local means filtering (NLM), both of which were superior to other comparators (OMP 37.6 ± 2.2, NLM 38.0 ± 1.8). The superior performance of our OMP denoising algorithm in comparison to traditional models is promising for clinical utility. Given its individualized and lightweight approach, implementation into PACS may be more easily incorporated. It is our hope that this technology will provide improved diagnostic accuracy and workflow optimization for Neurologists and Radiologists, as well as improved patient outcomes.

Induction of pancreatic neoplasia in the KRAS/TP53 Oncopig.

The 5-year survival of pancreatic cancer (PC) remains low. Murine models may not adequately mimic human PC and can be too small for medical device development. A large-animal PC model could address these issues. We induced and characterized pancreatic tumors in Oncopigs (transgenic swine containing KRASG12D and TP53R167H). The oncopigs underwent injection of adenovirus expressing Cre recombinase (AdCre) into one of the main pancreatic ducts. Resultant tumors were characterized by histology, cytokine expression, exome sequencing and transcriptome analysis. Ten of 14 Oncopigs (71%) had gross tumor within 3 weeks. At necropsy, all of these subjects had gastric outlet obstruction secondary to pancreatic tumor and phlegmon. Oncopigs with injections without Cre recombinase and wild-type pigs with AdCre injection did not show notable effect. Exome and transcriptome analysis of the porcine pancreatic tumors revealed similarity to the molecular signatures and pathways of human PC. Although further optimization and validation of this porcine PC model would be beneficial, it is anticipated that this model will be useful for focused research and development of diagnostic and therapeutic technologies for PC. This article has an associated First Person interview with the joint first authors of the paper.

Comparing Practices Used in Overdose Fatality Review Teams to Recommended Implementation Guidelines.

OBJECTIVES: Overdose fatality review teams are a public health and public safety collaboration that reviews fatality cases using a multidisciplinary team to provide recommendations for overdose prevention. No research exists on the case review practices currently being used in these programs. DESIGN: We administered a cross-sectional survey measuring case review practices and perceptions to a convenience sample of overdose fatality review teams. SETTING: We administered the online survey to participants at a national virtual forum on overdose fatality review. PARTICIPANTS: In this study, we examined 30 county-level overdose fatality review teams from 6 states who completed the survey. MAIN OUTCOME MEASURES: We developed measures of case review practices from an overdose fatality review implementation guide. We provided descriptive statistics on the survey items used to measure these practices and examined how practice uptake varied by overdose fatality review team characteristics. RESULTS: Most overdose fatality review teams had adequate representation and membership, but none adhered to all of the practices measured from the implementation guide. The largest gap was in perceived effectiveness and implementation of case review recommendations. In addition, teams that had been reviewing cases for longer reported more adherence to recommended practices. CONCLUSIONS: Overdose fatality case review is a collaboration between local public health and public safety agencies that holds great promise. However, these teams will require additional training and technical assistance with local community support to ensure that recommendations are actionable.

Correlates of recent overdose among people who inject drugs in the San Diego/Tijuana border region.

BACKGROUND: Along the Mexico-US border, illicitly manufactured fentanyls (fentanyl) have been detected in other illicit drugs, including street opioid formulations known as 'china white.' We studied correlates of recent overdose among people who inject drugs (PWID), focusing on the risk of knowlingly or unknowingly using fentanyl in china white. METHODS: From October 2020 - September, 2021 we surveyed participants in San Diego, California and Tijuana, Mexico and employed Poisson regression to identify correlates of recent overdose. RESULTS: Of 612 PWID, most were male (74.0 %), Latinx (71.9 %), US residents (67.0 %). Mean age was 43 years. In the last six months, 15.8 % experienced overdose, 31.0 % knowingly used fentanyl and 11.1 % used china white, of whom 77.9 % did not think it contained fentanyl. After controlling for sex and race, factors independently associated with risk of overdose included knowingly using fentanyl, using china white and not believing it contained fentanyl, recent drug rehabilitation, being stopped/arrested by police, and homelessness. Further, PWID who believed china white contained fentanyl were less likely to use it. CONCLUSIONS: Both intentional fentanyl use and unintentional exposure to fentanyl via china white were associated with overdose risk; however, PWID who believed china white contained fentanyl were less likely to use it. These data suggest that advanced drug checking systems should be implemented to empower PWID to avoid dangerous street formulations or to plan their drug use knowing its contents. Other overdose risk factors such as decreased tolerance following drug treatment, police interactions, and homelessness also require urgent intervention.

Large Animal Models of Breast Cancer.

In this mini review the status, advantages, and disadvantages of large animal modeling of breast cancer (BC) will be discussed. While most older studies of large animal BC models utilized canine and feline subjects, more recently there has been interest in development of porcine BC models, with some early promising results for modeling human disease. Widely used rodent models of BC were briefly reviewed to give context to the work on the large animal BC models. Availability of large animal BC models could provide additional tools for BC research, including availability of human-sized subjects and BC models with greater biologic relevance.

Evaluation of a Police-Mental Health Co-response Team Relative to Traditional Police Response in Indianapolis.

OBJECTIVE: Criminal justice and emergency medical service (EMS) outcomes were compared for individuals experiencing a behavioral health crisis who received a response from a co-response team (CRT) or a usual response from the police after a 911 call. METHODS: A prospective, quasi-experimental design was used to examine outcomes of a CRT pilot tested in Indianapolis (August-December 2017). Weighted multivariable models examined effects of study condition (CRT group, N=313; usual-response group, N=315) on immediate booking, emergency detention, and subsequent jail bookings and EMS encounters. Sensitivity of outcomes to follow-up by a behavioral health unit (BHU) was also examined. RESULTS: Individuals in the CRT group were less likely than those in the usual-police-response group to be arrested immediately following the 911 incident (odds ratio [OR]=0.48, 95% confidence interval [CI]=0.25-0.92) and were more likely to experience any EMS encounter at 6- and 12-month follow-up (OR range=1.71-1.85, p≤0.015 for all). Response type was not associated with jail bookings at 6 or 12 months. Follow-up BHU services did not reduce bookings or EMS encounters. CRT recipients with BHU follow-up were more likely than those without BHU follow-up to have a subsequent EMS contact (OR range=2.35-3.12, p≤0.001 for all). These findings differed by racial group. CONCLUSIONS: CRT responses may reduce short-term incarceration risk but not long-term EMS demand or risk of justice involvement. Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.

Crisis event dispositions following a crisis response team intervention.

OBJECTIVE: We examined dispositions of crisis response team (CRT) events over 2 years in a large Midwestern city. METHOD: Between January 1, 2018 and December 31, 2019, the CRT self-dispatched to mental/behavioral health-related 9-1-1 calls. Data utilized for analysis included demographic information of persons in crisis, crisis type, and crisis event dispositions. Crisis types were mental health, self-harm, and substance use related. Event dispositions included immediate detention, arrest, transport, and issue resolved. Multinomial regression models were used to predict crisis event dispositions as a function of the three crisis types, controlling for covariates. The sample included 1,426 events to distinct individuals. RESULTS: Most CRT events involved persons who were White (47.7%; n = 680), male (56.1%; n = 800), and an average of 39.3 years of age (SD = 16.6). Most crises were mental health (65.4%; n = 932), followed by self-harm (31.7%; n = 452), and substance use (25.9%; n = 370). Events were generally resolved at the scene (55.0%, n = 784); over a quarter resulted in immediate detention (26.9%, n = 384), followed by voluntary transport (14.0%, n = 200), and arrest (4.1%, n = 58). Crisis type was a significant predictor of event dispositions: Self-harm crises were associated with immediate detention and voluntary transport, and substance use crises with arrest. Homelessness was also a significant predictor of arrest. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The findings provide a better understanding of the short-term impact of CRTs. Data highlight how crisis type indicators predict event dispositions, demonstrating potential for more efficient emergency responder utilization by dispatching units according to crisis type. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Porcine pancreatic ductal epithelial cells transformed with KRASG12D and SV40T are tumorigenic.

We describe our initial studies in the development of an orthotopic, genetically defined, large animal model of pancreatic cancer. Primary pancreatic epithelial cells were isolated from pancreatic duct of domestic pigs. A transformed cell line was generated from these primary cells with oncogenic KRAS and SV40T. The transformed cell lines outperformed the primary and SV40T immortalized cells in terms of proliferation, population doubling time, soft agar growth, transwell migration and invasion. The transformed cell line grew tumors when injected subcutaneously in nude mice, forming glandular structures and staining for epithelial markers. Future work will include implantation studies of these tumorigenic porcine pancreatic cell lines into the pancreas of allogeneic and autologous pigs. The resultant large animal model of pancreatic cancer could be utilized for preclinical research on diagnostic, interventional, and therapeutic technologies.

Peer recovery services for persons returning from prison: Pilot randomized clinical trial investigation of SUPPORT.

Previously incarcerated persons with substance use disorder (SUD) need recovery supports, given the overrepresentation of this population in prison and community supervision. Peer support programs have the potential to fill gaps in postrelease support for persons with SUD. To assess the effectiveness of peer support approaches, this pilot study randomized access to peer recovery coaches within a well-established community reentry program. We examined several proximal outcomes to determine potential mechanisms of action, along with several exploratory outcomes. While attrition due to re-incarceration, death, and program disengagement was high, our findings suggest that those who received peer recovery coach support in the reentry program had recovery-based improvements, including improved self-reported mental and physical health and reductions in substance use behaviors. The treatment group also saw improvements in measures of treatment motivation and self-efficacy. Both groups saw similar positive trends in some outcomes, likely due to the relative success of the well-established reentry program regardless of the inclusion of peer support coaches. This study contributes lessons learned and potential mechanisms of action to limited research on the effectiveness of peer recovery supports for reentry populations with SUD.

Community overdose surveillance: Comparing substances collected from the death scene investigation to toxicology results.

BACKGROUND: Recent overdose trends are characterized by increased toxicological detection of stimulants with opioids, yet it is unclear whether these substances are mixed prior to consumption or purposefully used simultaneously. METHODS: Postmortem toxicology data were collected in Marion County, Indiana, from 45 fatal overdose cases involving heroin, fentanyl, methamphetamine, or cocaine. Substances found by death scene investigators at the scene of the fatal overdose (57 samples) were tested using high-pressure liquid chromatography mass-spectrometry (LC-MS) technology. We compared toxicology and LC-MS results to understand whether substances contributing to overdose were found in combination or separately at the scene of the overdose. RESULTS: Comparing toxicology reports with LC-MS results from substances found at the scene of overdose deaths involving opioids and stimulants reveal that deaths are largely the result of the co-use of opioids and stimulants, rather than use of stimulants combined with opioids. CONCLUSIONS: Collecting and testing physical samples from fatal overdose scenes and comparing these to post-mortem toxicology results is a new way to examine polydrug use patterns. This community overdose surveillance method can be used to improve overdose prevention and response efforts.

Buprenorphine Treatment Intake and Critical Encounters following a Nonfatal Opioid Overdose.

BACKGROUND: Individuals with prior opioid-related overdose events have an increased risk for opioid-related mortality. Buprenorphine is a partial agonist that has shown to be an effective medication for opioid use disorder (MOUD). Yet, few studies have investigated whether buprenorphine reduces the risk of opioid-related mortality following a nonfatal opioid-related overdose. METHODS: A retrospective study was conducted on all overdose cases in Indiana between January 1, 2017 and December 31, 2017. Data were linked from multiple administrative sources. Cases were linked to vital records to assess mortality. Bivariate analyses were conducted to assess group differences between survivors and decedents. A series of multiple logistic regression models were used to determine main and interaction effects of opioid-related mortality. RESULTS: Among the 10,195 nonfatal overdoses, 2.4% (247) resulted in a subsequent fatal overdose. Overdose decedents were on average 36.4 years-old, 66.8% male, 91.1% White, and 83.8% did not receive a buprenorphine dispensation. Incremental increases in the number of buprenorphine dispensations decreased the likelihood of fatal overdose by 94% (95% CI = 0.88-0.98, p = .001). Incremental increases in arrest encounters were found to significantly increase the likelihood of a fatal overdose (AOR = 2.16; 95% CI = 1.13-3.55). Arrest encounters were a significant moderator of the relationship between buprenorphine uptake effectiveness and drug-related mortality. CONCLUSIONS: Analysis of linked data provided details of risk and protective factors of fatal overdose. Buprenorphine reduced the risk of death; however, criminal justice involvement remains an area of attention for diversion and overdose death prevention interventions.

Designing and implementing an intervention for returning citizens living with substance use disorder: discovering the benefits of peer recovery coach involvement in pilot clinical trial decision-making.

Peer-facilitated services in behavioral health care remain underutilized within criminal justice-involved community organizations, and there is little guidance for how to best involve peer workers in behavioral health-focused research activities. This paper described lessons learned regarding implementation of peer recovery coaches (PRCs) as part of development and pilot research on Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT), a peer-facilitated substance use disorder (SUD) intervention for returning citizens. Qualitative data were collected from learning meetings with key stakeholders and group interviews with SUPPORT clinical trial participants and PRCs. Transcripts were analyzed to identify key decisions made impacting the development, implementation, and/or revision of the SUPPORT intervention and pilot clinical trial protocols. Analysis demonstrated that PRC involvement drove many of the decisions made regarding modifications to the original intervention and trial protocols, while benefitting client-level interactions and by influencing the non-profit agency and its connection to stakeholders. Moreover, PRCs improved the research design by refining the incentive structure and data collection plans. PRC involvement also contributed to the development of more recovery-oriented resources and catering support services to the unique needs of justice-involved individuals. Discussed were the implications for the role of PRCs in justice-involved behavioral health research and treatment.

Arrest and emergency medical services events among participants from one of the first mental health courts.

OBJECTIVE: This study looked at, in addition to subsequent arrest, emergency medical services (EMS) events as an outcome of participation in mental health court (MHC). METHODS: We linked information from participants of a MHC in Marion County, Indiana with jail booking and EMS services data. To understand programmatic impact, we looked at differences in jail bookings and EMS events within one year prior to and one year after MHC participation. We ran paired t-tests to understand whether correlations were significant. We also considered differences in outcomes between those who successfully completed MHC versus those who did not. RESULTS: MHC participation was significantly associated with a reduction in jail bookings and EMS events in the 12 months after program participation compared to the 12 months before. When comparing MHC participant groups, a significant reduction in jail bookings is found consistently whereas a significant reduction in EMS events was found in only some participant groups: the entire MHC group and the misdemeanor-level court (PAIR) participants when they successfully completed the program. CONCLUSIONS: EMS utilization should be an outcome of consideration in evaluating the success and cost savings of MHCs. Where MHCs do not result in significantly reduced EMS events, communities should consider what individual-level and community-level factors contribute to this and adjust accordingly.

An aortic wall to vertebral body fistula presenting as a lytic lesion.

There have been multiple reported cases of aortic fistulas but few cases of aorta to vertebral body fistulas and no aortic wall to vertebral body fistulas have been reported. Here we present a case of a patient who is status post thoracic aortic aneurysm (TAA) repair and found to have a lytic vertebral body lesion. Biopsy of the mass revealed blood products without evidence of malignancy and further investigation revealed a fistulous tract between the aortic wall and the vertebral body causing a vertebral body hematoma.

Racial differences in overdose events and polydrug detection in Indianapolis, Indiana.

BACKGROUND: We examine racial disparities in drug overdose death rates by analyzing trends in fatal and nonfatal overdose outcomes in a large metropolitan area (Indianapolis, Indiana). METHODS: Death certificate and toxicology records for accidental drug overdose deaths from 2011 to 2018 were linked with emergency medical services (EMS) data. Bivariate comparisons examined differences in toxicology findings at the time of death as well as prior EMS events both overall and by indicator of non-fatal overdose. RESULTS: From 2011-2018, 2204 residents (29.4 per 100,000) died of drug overdose, 18.6% were Black (N = 410, 19.5 per 100,000) and 78.5% White (N = 1730, 35.2 per 100,000). In the year prior to death, 33.5% (N = 656) of decedents had an EMS event, 12.1% (N = 237) had an overdose event, and 9.4% (N = 185) had naloxone administered. Overdose complaint and naloxone administration were more likely to occur among White than Black patients. White decedents were more likely than Black decedents to have had naloxone administered in the year prior to death (10.1% vs. 6.8%, χ2 = 4.0, p < .05, Cramer's V=.05). Toxicology data illustrate changing polydrug combinations, with Black decedents more likely to test positive for fentanyl-cocaine polydrug use in recent years. CONCLUSIONS: Recent racial disparities in overdose deaths are driven by a combination of fentanyl and cocaine, which disproportionally impacts African American drug users, but may be addressed through expanded harm reduction and community outreach services. Additionally, there is a need to assess the role of differing practices in overdose emergency service provision as a contributing factor to disparities.

Police officer attitudes towards syringe services programming.

BACKGROUND: As the United States experiences a drug overdose epidemic, syringe services programs (SSPs) have been utilized to reduce rates of infectious disease and improve treatment outcomes for people who inject drugs (PWID). Police officer support of SSPs is crucial to program success. One way to improve officer support and collaboration is to develop officer training presentations about SSP services and procedures as well as information on officers' roles in program implementation. METHODS: Researchers accompanied staff from the Marion County Safe Syringe Access and Support Program as they provided SSP training presentations to Indianapolis Metropolitan Police Department officers at district roll calls. Immediately following each presentation, officers completed a survey measuring attitudes toward SSPs, PWID, and the information presented. RESULTS: Of the 339 completed surveys returned, most officers expressed support for the SSP and a desire to help PWID. However, those with experience of a needle stick injury were more critical of the program, reporting it enables drug use. Approximately half of respondents reported limited knowledge of SSPs, even after the training. Qualitative data indicate about half of officers reported they could use discretion in deciding whether to arrest for illegal possession of a syringe. CONCLUSIONS: Overall findings indicate positive attitudes towards SSPs; however, officer feedback identifies several concerns and areas for improvement. Public health agencies must develop comprehensive, tailored presentations that address common officer concerns and misconceptions regarding SSPs, PWIDs, and harm reduction strategies to improve officer support.